Pilot Study to Assess the Effectiveness of the Sustainable Culturally Adaptive Nutrition Program (SCAN) to Improve Adherence to the National Diabetes Prevention Program

Purpose The Sustainable Culturally Adapted Nutrition Program (SCAN) is a novel adaptation to the National Diabetes Prevention Program (NDPP) that aims to improve attendance and effectiveness. This paper presents its feasibility and impact through the initial 6-month outcomes. Design A pragmatic quasi-experimental pilot study with intervention (DPP plus SCAN) and control (DPP only) groups. Samples and Inclusion Criteria Sustainable Culturally Adapted Nutrition Program participants were recruited from federally qualified health center (FQHC) clinic patients enrolled in a NDPP in Houston, Texas. Participants needed to be (1) ≥18 years old, (2) body mass index >25, (3) no prior diagnosis of diabetes, and (4) not pregnant. Intervention Sustainable Culturally Adapted Nutrition Program cooking classes were designed to teach skills to prepare fresh produce, and utilized Motivational Interviewing (MI) techniques to encourage participants to adapt these skills for foods that were culturally important to them. Outcome Measures (1) National Diabetes Prevention Program attendance, (2) BMI and (3) percent weight loss. Analysis We used linear mixed models to test the association between weights and NDPP attendance. Results 22 intervention and 15 control participants completed the program to the 6-month point. Intervention participants had increased DPP attendance over controls (7.14 vs 6.87 session). Intervention participants also demonstrated on average, 1.5% weight loss for each additional SCAN class attended (P = .144). Conclusions The SCAN adaptation shows promising results for effectively increasing both NDPP attendance and weight loss.

The National Diabetes Prevention Program (National DPP) is a 12-month evidence-based lifestyle change program implemented to reduce the incidence of Type 2 Diabetes Mellitus among individuals with prediabetes. 1 Health outcomes are dependent on class attendance and adherence to program recommendations, 1 but despite the benefits of the National DPP, they remain low in many populations, which reduces the overall efficacy of their programs. 1o address this gap in the continuity of preventive care for primary care patients with prediabetes, we developed the Sustainable Culturally Adapted Nutrition (SCAN) program to improve patient attendance and adherence to the National DPP by decreasing environmental (eg, access to food) and personal barriers (eg, lack of cooking skills, and motivation) to participation.This paper reports the association between SCAN participation and attendance in a National DPP and the impact on participants' weight.

Design
A pragmatic quasi-experimental pilot study in an urban federally qualified health center assessed the effectiveness of SCAN, which included 2 program components: Food Prescription (Rx) Program and culturally adapted cooking classes.The UTHealth Committee for the Protection of Human Subjects approved all study procedures.

Sample
Recruitment took place between July and September of 2021.To be considered eligible, patients needed to satisfy all the following criteria: (1) at least 18 years of age, (2) body mass index (BMI) greater than 25, (3) no prior diagnosis of Type 1 or Type 2 diabetes, and (4) not pregnant.Subsequently, an eligible patient must satisfy at least 1 of the following requirements: (1) blood test result in the prediabetes range (Hemoglobin A1C: 5.7-6.4%),(2) previous diagnosis of gestational diabetes, or (3) Prediabetes Risk Test score greater than 5. Eligible patients were identified by healthcare providers from Hope Clinic, a federally qualified health center (FQHC) in Houston Texas, selected to take part in this pilot study, given its participation with UTHealth. 2We conveniently selected 4 DPP cohorts/classes of at most 15 participants each as part of the SCAN pitot study.We randomized 4 cohorts at the class/cohort level into control groups (1 English and 1 Spanish speaking cohort) and intervention groups (1 English and 1 Spanish speaking cohort) as part of the control group.From an original 61 sample, we included 37 participants (22 in the intervention and 15 in control group) in the preliminary analyses.

Measures
National DPP attendance and percent weight loss are the primary outcomes of interest for the pilot study measured at 6months and 12 months post-intervention.Secondary measures include anthropometric (weight and body mass index) and biometric (HgbA1C, LDL, HDL, and Triglycerides) abstracted from the Hope clinic at baseline, 6 months, and will be measured 12 months post-completion.

Intervention
The intervention group received 4 SCAN cooking classes, a food prescription (ie, Food RX), and incentives (ie, cooking tools and necessary food to participate in the cooking classes), while the control group only received the food prescription.The cooking class curriculum included recipes and activities developed in collaboration with the Nourish Program, 3 based on the Social Cognitive Theory, and aimed to increase participants' outcome expectations of the taste of healthy foods, knowledge, and self-efficacy for engaging in healthy eating, culinary skills, and social support of preparing healthy foods. 4

Analysis
We performed a descriptive analysis to describe participants' sociodemographic characteristics (age, race, sex, ethnicity, education, and language), anthropometric measures at baseline (weight, blood pressure, BMI, HgbA1C, HDL, and LDL), and Prediabetes Risk Test [yes/no].We compared the differences between the intervention and control group using a two-sample t test for continuous variables and a chi-square or fisher exact test for discrete data.
We used linear regression models to test the association between National DPP attendance and (1) completion of SCAN sessions; and linear mixed model to test the association with (2) weight loss to account for the correlation of repeated measures within each subject.

Results
We used the intent to treat analysis.Of the 61 National DPP participants enrolled in SCAN; 37 attended at least 1 National DPP class, but 1 did not enroll in the Food RX program; 24 were excluded from analysis since they did not attend either DPP or SCAN session and no baseline information was obtained to include them in the study.The participants in the intervention group were younger (46.6 ± 12.20 vs 50.47 ± 9.06; P > .05),female (72.70 % vs 60% %; P > .05),and Hispanic (73.7 % vs 33.3 %; P > .05)compared to the intervention group (data not shown).No statistically significant associations were shown comparing sociodemographic characteristics and baseline anthropometric measures between the groups.Lastly, less than 10% of the total National DPP participants utilized Food Rx.
At 6 months into the National DPP program, attendance was higher among participants in the intervention group (7.14 ± 4.60; P > .05)compared to those in the control group (6.87 ± 5.73; P > .05)(Table 1).Even though the SCAN sessions were not significantly different between the intervention and control groups (P-value = .875),attending SCAN sessions did show association with weight loss.Attending each additional SCAN session reduced National DPP participants' average weight by 1.5% (Table 2).Although not significant, the study revealed a greater dose-response association between the number of National DPP sessions attended and participants' average weight loss among participants in the intervention group compared to those in the control group (data not shown).The biometric data was not significant from baseline to 6 months (data not shown).

Table 1 .
DPP Attendance at the 6 Months Mark of the 37 DPP Patients Enrolled in the Socially Culturally Adapted Nutrition (SCAN) program Control vs Intervention.

Table 2 .
Longitudinal Association Log (Weight) on DPP Sessions Attended and Time in Days.Ph.D., M.A., M.P.H., Shreela Sharma, PhD., Jacklyn Hecht, RN, MSN., Paige Boyer, M.P.H., Esther Liew, MSW, John W. McWhorter, Dr.Ph.Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This manuscript was supported by the Centers for Disease Control and Prevention of the US Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3.8 million with 100 percent funded by CDC/HHS (project No. HHS001000100001).The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by Texas DSHS (Department of State Health Services), CDC/HHS, or the US Government.This research was partially funded by the Centers for Disease Control and Prevention/National Institute of Occupational Safety and Health (Award No. T42OH008421) through the Southwest Center for Occupational and Environmental Health (SWCOEH).The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention/National Institute of Occupational Safety and Health.ORCID iDsWilliam B. Perkison  https://orcid.org/0000-0003-3079-6217Natalia I. Heredia  https://orcid.org/0000-0001-8086-3700Maria E. Fernandez  https://orcid.org/0000-0002-7979-7379